ASSURANCE FRAMEWORK
Date: December 2009
Version: 28
CONTENTS
PAGE1.0 / THE ASSURANCE FRAMEWORK – BACKGROUND / 5
2.0 / ASSURANCE FRAMEWORK – DEFINITIONS / 6
3.0 / PRINCIPAL OBJECTIVES / 7
3.1
3 x3 = 9
Medium / Principal Objective One (Linked to performance target Q1, Q2, Q3, Q4, Q5, P1, P2, P3, P4 and corporate strategic risk 463)
Maintaining clinical excellence
To be the pre-eminent effective, efficient and safe provider of orthopaedic and musculo-skeletal services, providing the highest standards of care
Monitoring Committee: Clinical Governance Committee / 7
3.2
4 x 4 = 16
High / Principal Objective Two(Linked to corporate strategic risks 463, 467, 470, 472)
Re-development and capital investment
To redevelop the RNOH Stanmore campus to provide a modern healthcare buildingand facilities.
To effectively use capital investment to improve the working environment and health and safety. To improve and sustain business activity. / 12
4 x 3 = 12
Medium / Monitoring Committee: Performance Committee andRisk Management Committee
3.3
4 x 5 = 20
High / Principal Objective Three (Linked to performance targetF1 and corporate strategic risk 468)
Finance
To achieve planned financial targets and maintain liquidity and increase turnover.
Monitoring Committee: Performance Committee / 21
3.4
3 x 3 = 9 2x4 = 12
Medium / Principal Objective Four(Linked to performance target M & L 1, M & L 2,
M & L 3 and corporate strategic risk 465)
Leadership and workforce
To ensure that the workforce is fit for purpose and supports the Trusts service and financial plans. / 24
2 x 3 = 6
Low / Monitoring Committee: Risk Management Committee
3.5
2 x4 = 8
Medium / Principal Objective Five(Linked to corporate strategic risks 464, 466)
Governance
To implement, embed and monitor effective arrangements that reflect current Trust business
High risks (20) = Failure to comply with national priorities. E.g. waiting list targets and Standards For Better Health
Monitoring Committee: Risk Management Committee and Clinical Governance Committee / 28
PAGE
3.6
3 x 4 = 12
High / Principal Objective Six (Linked to performance target A1, A2, A3, A4, P1, P2, P3, P4 and corporate strategic risk 463)
Achievement of access / activity targets
To achieve access targets and to deliver the activity targets.
Monitoring Committee: Performance Committee / 32
3.7
2 x4 = 8
Medium / Principal Objective Seven (Linked to corporate strategic risk 471)
IM&T
Develop and implement a cohesive and integrated IM&T strategy.
Monitoring Committee: PerformanceCommittee / 35
3.8
4 x 4 = 16
High / Principal Objective Eight (Linked to corporate strategic risks 463, 467, 469,472,)
Foundation Trust
To achieve Foundation Trust status
Monitoring Committee: Performance Committee / 38
4.0 / APPENDIX ONE: Trust Performance Targets / 40
5.0 / APPENDIX TWO: Risk Register / 41
5.1 / Risk Register / 41
5.2 / Role of Risk Manager / 41
5.3 / Information Sources / 41
5.4 / Reporting Arrangements / 42
5.4.1 / Trust Board / 42
5.4.2 / Risk Management Committee / 42
5.4.3 / Audit Committee / 42
5.4.4 / Executive Team / 42
5.5 / RISK CLASSIFICATION MATRIX / 42
5.5.1 / Potential Outcome Severity Matrix – Definitions / 42
5.5.1.1 / Likelihood / 42
5.5.1.2 / Severity / 43
5.5.1.3 / Risk Rating And Action Plan / 43
5.5.2 / Matrix / 44
PAGE
6.0 / APPENDIX THREE: Redevelopment and capital investment – directorate level investment – Six facet estatecode survey descriptor / 45
1.0THE ASSURANCE FRAMEWORK - BACKGROUND
To ensure that the Board is confident that the systems, policies and people that are in place are operating in a manner that is effective in driving the delivery of objectives by focusing on minimising risk an assurance framework has been developed. This framework provides the Trust with a simple but comprehensive method for the effective and focused management of the principal risks to meeting our principal objectives. The framework has been developed by Board members in conjunction with the Risk Manager and is monitored and reviewed through the following mechanisms: -
- the framework is sent to the Executive Team every second month in order that they can monitor and review the contents. Each director is responsible for informing the Risk Manager of any modifications that are required
- Risk Management Committee reviews the assurance framework at all meetings. (every eight weeks)
- the Trust Board receive a copy of the document every second meeting for review
Each of the eight principal objectives within the Assurance Framework are linked to the Integrated Business Plan, the performance targets and the risks detailed within the corporate strategic risk register.
The Assurance Framework provides the Trust with a simple but comprehensive method for the effective and focused management of the principal risks to meeting their objectives. It also provides a structure for the evidence to support the Statement On Internal Control. This simplifies Board reporting and the prioritisation of action plans, which, in turn, allow for more effective performance management.
Appendix one provides an explanation of how the risk register is developed, reviewed and monitored.
1
2.0ASSURANCE FRAMEWORK - DEFINITIONS
Principal objectives / Description of all associated risks / Key Controls / Assurances on controlsand assurance level / Gaps in controls / Gaps in assurances / Risk rating
(L x C) / Action plan and completion date / Board lead
Objectives set at strategic and directorate level. The objectives must be SMART.
Links to performance targets and corporate strategic risk register are detailed.
Key to targets:
Q = Quality
A = Access
D = Financial
M & L = Management and leadership
P = Productivity / Risks which threaten the achievement of the principle objective.
When considering the severity of a risk we consider it in terms or the likelihood of it arising and the consequences should it arise. / A control is something which occurs or is in place to mitigate the likelihood of the risk arising or the impact of the risk should it arise. A control should be well defined in order that its effectiveness can be assessed.
The following should not be included within the control column – “documented policies and procedures..2 A clear description of a control should be included such as the name and date of the policies and procedures. / Refer to the various reviewers, auditors and inspectors, both internal and external. The Board must determine which sources of assurance are relevant to the principle risks and to what extent they are sufficient. Specific reference must be made to the sources of assurance documented. It is not acceptable to merely state “internal audit report”
Assurance level is self assessed and defined as:
- Substantial
- Adequate
- Limited
There should be a natural link between this column and the “actions” column. / A gap in assurance exists where the Trust has identified that there is a control it believes is in operation but which it has not had assured as to how effectively this is operating. A gap in assurance would occur where there has been no independent assessment of the control identified. Additionally it is essential that gaps in assurance are documented sub objectives where the control is in operation but not obtained any assurance as to how they are operating / Refer to attached risk classification matrix / A comprehensive action plan is required detailing how the risks associated with the achievement of each objective will be managed and reduced as far as is reasonably practicable.
For each action include:
- Proposed date for completion.
- Revised date for completion.
- Responsible director.
1
3.0PRINCIPAL OBJECTIVES
3.1PRINCIPAL OBJECTIVE ONE – MAINTAINING CLINICAL EXCELLENCE Monitoring Committee: Clinical Governance Committee
Principal objectives / Description of all associated risks / Key Controls / Assurances on controlsand assurance level / Gaps in controls / Gaps in assurances / Risk rating
(L x C) / Action plan and implementation
date / Board lead
To be the pre-eminent effective and efficient provider of orthopaedic and musculo-skeletal services, providing the highest standards of care.
(Source: Integrated Business Plan 2008: Section 3 and 9)
(Linked to performance target Q1, Q2, Q3, Q4, Q5, P1, P2, P3, P4)
(Linked to corporate strategic risk 463) / Failure to sufficiently and effectively cooperate with other healthcare / social care organisations to ensure that patient’s individual needs are properly managed and met. / Performance monitoring.
Service level agreements.
Patient Satisfaction Surveys
Provider Sustainability Plan – November 2005. Page 21
Commissioning Forum
Collaborative commissioning arrangements reviewed (2006)
Lead PCT arrangements established with PCT’s.
Monthly monitoring meetings.
Patient Safety First Campaign
Links with patient forum and LINKS network / Patient Advice Liaison Service (PAL’s) issues and complaints.
Adequate
Patient Satisfaction Survey (Nov 2007)
Substantial
Annual clinical audit reports.
Adequate
Standards For Better Healthcare (C1, C2, C3, C5, C6, C21)
Substantial
Healthcare Commission review
Substantial / Need to develop further links between patient feedback and service change. / No gaps in assurance have been identified. / 3 x 3 = 9
Medium / Revision of complaints procedure.
(December 2009) / Director of Nursing / Medical Director
Principal objectives / Description of all associated risks / Key Controls / Assurances on controls
and assurance level / Gaps in controls / Gaps in assurances / Risk rating
(L x C) / Action plan and implementation
date / Board lead
To be thepre-eminent effective and efficient provider of orthopaedic and musculo-skeletal services, providing the highest standards of care. / Failure to sufficiently and effectively cooperate with other healthcare / social care organisations to ensure that patient’s individual needs are properly managed and met. (continued)
Failure to provide healthcare in partnership with patients, their carers and relatives, respecting their diverse needs, preferences and choices, and in partnership with other organisations (especially social care organisations) whose services impact on patient well-being. / Systematic approach to noting and acting upon themes from complaints.
Annual HCC / CQQ Standards For Better Health assessment action plans.
Clinical standards
Benchmarking / Incident reporting
Adequate
Key indicators
Adequate
Weekly quality audit
Substantial
Clinical Governance report discussed and action at directorate monthly performance reviews.
Adequate
Patient Experience Group (reviewing complaints, privacy and dignity issues, real time feedback)
Adequate / No gaps in controls have been identified / Real time patient feedback yet to be implemented. / 3 x 3 = 9
Medium / Implement real time patient feedback.
(December 2009)
Progress report – December 2009: This project has commenced / Director of Nursing
1
Principal objectives / Description of all associated risks / Key Controls / Assurances on controlsand assurance level / Gaps in controls / Gaps in assurances / Risk rating
(L x C) / Action plan and implementation
Date / Board lead
To be the pre-eminent effective and efficient provider of orthopaedic and musculo-skeletal services, providing the highest standards of care. / Failure to effectively enhance patient safety by the use of healthcare processes, working practices and systematic activities that prevent or reduce the risk of harm to patients. / Clinical policies and procedures
Root cause analysis policy / Clinical Governance report discussed and action at directorate monthly performance reviews.
Adequate
Root cause analysis reports
Substantial / No gaps in controls have been identified / No gaps in assurance have been identified. / 3 x 3 = 9
Medium
Failure to comply with the Health Act 2006: The Code Of Practice For The Prevention And Control Of Healthcare Associated Infections (DH 2006)
Failure to meet standards for privacy and dignity. / Annual Infection Control Programme (Board 2008)
Clinical Audit Lead / Saving Lives audit
Substantial
HCC Hygiene Code visit 2008
Substantial
Infection control surveillance
Substantial
Quality monitoring tool (matrons)
Adequate
Patient Experience Group (reviewing complaints, privacy and dignity issues, real time feedback)
Adequate / No gaps in controls have been identified / No gaps in assurance have been identified.
No gaps in assurance have been identified. / 3 x 3 = 9
Medium
3 x 3 = 9
Medium / Implement infection control action plan.
Develop Privacy and Dignity audit tool
(September 2009)
Progress report – December 2009: Use of tool is being monitored / Director of Nursing
Director of Nursing
Principal objectives / Description of all associated risks / Key Controls / Assurances on controls
and assurance level / Gaps in controls / Gaps in assurances / Risk rating
(L x C) / Action plan and implementation
Date / Board lead
To be the pre-eminent effective and efficient provider of orthopaedic and musculo-skeletal services, providing the highest standards of care. / Risk of significant impact on the Trust’s capacity and operations due to the pandemic swine flu virus. / Director of Nursing is the nominated Executive Director leading on H1N1 flu.
Pandemic Flu Policy (approved April 2009)
Weekly Flu Planning meeting chaired by the Director of Nursing. This includes:
- Plans for communications, vaccination and admission management.
- Hospital stocks of specialist equipment and drugs available.
Human Resources have introduced additional staff monitoring procedures and advice for staff. / No gaps in assurance have been identified. / 3 x 3 = 9
Medium
Principal objectives / Description of all associated risks / Key Controls / Assurances on controls
and assurance level / Gaps in controls / Gaps in assurances / Risk rating
(L x C) / Action plan and implementation
Date / Board lead
To be the pre-eminent effective and efficient provider of orthopaedic and musculo-skeletal services, providing the highest standards of care. / Risk of significant impact on the Trust’s capacity and operations due to the pandemic swine flu virus. (continued) / Daily updates received by the Trust on the national position and DH policy clarification as the situation develops.
Report to Trust Board on winter planning pressures and flu planning. / 3 x 3 = 9
Medium
3.2Principal Objective Two – Redevelopment and capital investment
Principal objective:
- To redevelop the RNOH Stanmore campus to provide a modern healthcare building and facilities
- To effectively use capital investment to improve the working environment and health and safety. To improve and sustain business activity.
Monitoring Committee: Performance Committee and Risk Management Committee
Area / Strategic Objectives / Directorate Level ObjectiveProjects, Estates and Facilities / To redevelop the RNOH Stanmore campus to provide a modern healthcare buildingand facilities
To effectively use capital investment to improve the working environment and health and safety. To improve and sustain business activity
(Source: Integrated Business Plan 2008: Section 3 and 7)
(Linked to corporate strategic risks 463, 467, 470, 472 ) / A large part of the RNOH estate and services are more than 60 years old and many of the buildings and services are past their useful life. Poor investment in backlog maintenance over the years has exacerbated this situation to a point where only a very few buildings remain serviceable and suitable for modern healthcare. The Trust in recent years has been subject to prosecution due to non-compliance. The current estate is not providing an inclusive environment i.e. one that can be used by everyone regardless of age, gender, ethnicity or disability as detailed in the six facet Estatecode surveys. Overall the Performance Indicators (PI’s) highlight an estate, which is near the end of its designed life and is in need of modernisation and rationalisation to achieve a modern and fit for purpose estate. (See Estates Strategy 2008). Examples of this are recent improvement notices from the Health & Safety Executive (HSE) and the London Fire & Emergency Planning Authority (LFEPA). A thorough review of the opportunities and risks presented by the site has identified a preferred option for development of the Stanmore site that supports the Trusts vision and service strategy. The preferred option is for a new hospital facility to be built in the central zone of the site. Under the Trust proposal a number of key buildings are retained and the Trust has ring fenced over the next three years its annual capital allocation to enable these buildings to be brought up to Estatecode condition B (acceptable standard). The proposal will completely eliminate nightingale wards in the hospital, provide 50% single rooms and maximise the provision of ensuite facilities in wards. The quality of the environment will be improved and the new development will provide a modern flexible healthcare building. In addition, the proposed solution also addresses the weakness in the performance of the retained estate by addressing the investment need to meet statutory requirements and is predicted to reduce backlog maintenance to nil by 2015 as shown in the table below:
This will enable the Trust to be compliant with NHS guidance documents i.e. Health Building Notes (HBN’s) and Health Technical Memorandums(HTM’s). The Estate risk profile will be reduced and the majority of embedded risks will be eradicated. There will be improved clinical adjacencies and the provision of an inclusive environment. The Trust has an approved Outline Business Case (July 2008) and an Estate Strategy in place to deliver the redevelopments proposals.
Refer to appendix threefor definitions of the six facet estatecode survey descriptor
PRINCIPAL OBJECTIVE TWO – RE-DEVELOPMENT AND CAPITAL INVESTMENT
Principal objectives / Estate Performance / Description of all Associated risks / Key Controls / Assurances on controlsand assurance level / Gaps in controls / Gaps in assurances / Risk rating
(L x C) / Action plan and implementation date / Board lead
To address the poorPhysical Condition of the Estate buildings / Only 18 % of the estate has been graded in condition B or above. This classification reflects the high levels of ageing and physically unsuitable estate, which will either require substantial investment or total replacement to bring it to an acceptable standard. / Insufficient funding to maintain or provide care in an environment that promotes patient and staff well-being and respect for patient’ needs and preferences. Failure of the estate to provide an inclusive environment.
Non compliance with HBN 04,06,07,08 09, 10, 13, 15, 16 and the DDA regulations. /
Board-approved Estate Strategy (November 2008) for the management of its buildings, land, plant and non-medical equipment that meets the requirements of its business plan and service strategy.
Planning groups areheld for new
developments
involving patientsand staff.
Approved OBC for site redevelopment
Annual capital allocation / Standards For Better Health final declaration (April 2008)
(Substantial)
SHA have decided to pursue Stanmore total development as preferred option and no other options are to be considered.
(Substantial)
Capital Planning Group
(Adequate) / Standards For Better Healthcare (C20, C21).
Insufficient annual capital investment. / Standards For Better Healthcare (C20, C21, not met).